REPUBLIC OF THE PHILIPPINES )

BAGUIO CITY ) S.S.

x-------------------------------------x

AFFIDAVIT OF LOSS

I, _________, of legal age, Filipino, single and a resident of ________________ after

having been duly sworn to in accordance with law, depose and state THAT:

1. I pawned a __________, with _________ Pawnshop located at __________ and for

which I was issued a receipt, however, the date of pawning, I can no longer recall;

2. On February 20, 2020, I was issued a renewed receipt, and I kept the said renewed
receipt at home for safekeeping but unfortunately the same got lost sometime May
2020;

3. Despite diligent search and efforts to locate the said receipt, I could not find the
same such that I believe that it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to enable
me to secure a duplicate or substitute copy of the receipt and/or redeem the above-
described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand this 28 th day of May 2020 in Baguio
City, Philippines.

______________
Affiant

SUBCRIBED AND SWORN TO before me this 28th day of May 2020 in Baguio City
Philippines, affiant is personally known me as the same person who executed the foregoing
Affidavit of Loss.

Doc. No. 217;

Page No. 44; Notary Public
Book No. II;
Series of 2020.